Horizon Home Care

“Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient’s mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient’s risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure the Plan of Care contained patient specific orders, individualized to the patient’s identified needs, and covered all pertinent interventions with reportable parameters for 7 (P-1, 2, 3, 4, 5, 6, 7) of 7 records reviewed, resulting in patients not receiving care specific to their needs and the potential for poor patient outcomes. Findings included: **Agency Policy: “Care Planning, Coordination of Services and Quality of Care – 5002,” (Effective 5/20). The policy states, “Policy: Patients are accepted for treatment on the reasonable expectation that an HHA can meet the patient’s medical, nursing, rehabilitative, and social needs in his or her place of residence… The individualized plan of care must specify the care and services necessary to meet the patient-specific needs as identified in the comprehensive assessment… The individualized plan of care must include the following: …Patient specific interventions…” P-5: The Start of Care (SOC) was dated 10/10/24. The Plan of Care (POC) identified diagnoses of Myelopathy Cervical Region, Hypertension and Weakness. During record review on 10/23/24, it was noted that the POC stated, “Orders For Discipline and Treatment: Notify Physician of 2 consecutive vital sign parameters out of range...” 2 consecutive vital signs out of range could potentially lead to poor patient outcomes related to timeliness in urgent care needs. P-6: The Start of Care (SOC) was dated 10/9/24. The Plan of Care (POC) identified diagnoses of Perforation of Intestine and Hypertension. During record review on 10/22/24, it was noted that the POC stated, “Orders For Discipline and Treatment: Notify Physician of 2 consecutive vital sign parameters out of range...” 2 consecutive vital signs out of range could potentially lead to poor patient outcomes related to timeliness in urgent care needs. P-7: The Start of Care (SOC) was dated 9/25/24. The Plan of Care (POC) identified diagnoses of Rhabdomyolysis, Cervical Disc Degeneration and Hypertension. During record review on 10/22/24, it was noted that the POC stated, “Orders For Discipline and Treatment: Notify Physician of 2 consecutive vital sign parameters out of range...” 2 consecutive vital signs out of range could potentially lead to poor patient outcomes related to timeliness in urgent care needs. These findings were reviewed with and acknowledged by the Adm-1 (Administrator) during an interview on 10/23/24 at 1:00 pm. P-1: The Start of Care (SOC) was dated 6/8/24. The Plan of Care (POC) identified diagnoses of dislocation of right ankle joint, hypo-osmolality, and hypertension. During record review on 10/22/24, it was noted that the POC stated, “Orders for Discipline and Treatment: Notify Physician of 2 consecutive vital sign parameters out of range...” Two consecutive out of range vital signs could potentially lead to poor patient outcomes related to timeliness in urgent care needs. P-2: The SOC was dated 7/3/24. The POC identified diagnoses of polymyalgia rheumatica, weakness, and congestive heart failure. During record review on 10/22/24, it was noted that the POC stated, “Orders for Discipline and Treatment: Notify Physician of 2 consecutive vital sign parameters out of range...” Two consecutive out of range vital signs could potentially lead to poor patient outcomes related to timeliness in urgent care needs. P-3: The SOC was dated 9/12/24. The POC identified diagnoses of dehydration, hypokalemia, and weakness. During record review on 10/22/24, it was noted that the POC stated, “Orders for Discipline and Treatment: Notify Physician of 2 consecutive vital sign parameters out of range...” Two consecutive out of range vital signs could potentially lead to poor patient outcomes related to timeliness in urgent care needs. P-4: The SOC was dated 1/4/24. The POC identified diagnoses of congestive heart failure, monoclonal gammopathy, and atrial fibrillation. During record review on 10/22/24, it was noted that the POC stated, “Orders for Discipline and Treatment: Notify Physician of 2 consecutive vital sign parameters out of range...” Two consecutive out of range vital signs could potentially lead to poor patient outcomes related to timeliness in urgent care needs. The findings were reviewed with and acknowledged by the administrator (Adm-1) during an interview on 10/23/24 at 1:30 p.m.”